Thursday, January 30, 2020

A clinical director recently shared a
concern in a staff meeting about an adolescent on probation. The treatment team
had built a program around the youth to address his sexually abusive behavior
and general mental health.Now, the
treatment team assessed him as being at low risk and were understandably proud
of their contributions to his progress in building a lifestyle incompatible
with causing harm to others. Their approach had been team-based,
multidisciplinary, and comprehensive. As he neared the end of treatment, his
probation officer expressed concerns. “As we all know,” he said, “his seemingly
good behavior is a huge red flag that things aren’t right,” which raised
concerns about the implications for the youth’s future, as well as their own
clinical judgment.

The treatment team found itself in a
paradox. If the young man were to behave badly, others would judge him to be in
need of treatment. If he behaved well, the natural assumption for some would be
that he must be behaving in a secretive manner.Those working in the field will recognize this as a belief that persists
in some quarters despite very strong evidence to the contrary. If your work is
simply about managing risk, it’s easy to see risk everywhere.

The impact on the young man’s treatment
team was apparent almost in its absence; they had heard this before. Despite a
solid base of scientific evidence, it would be difficult to convince others
that this young man really was more than the sum of his worst behavior.
Although he posed a low risk to abuse again, the team recognized that he was at
very high risk to be prevented from living up to his full potential. Concerning
to the author who sat in on this team meeting was that the staff had heard this
all before. They have spent their careers aware of risks, helping people
change, and being merchants of hope for young people in their families, all the
while surrounded by people who would not support their efforts.

To be blunt, these experiences of
disrespect have a cumulative effect and cause harm to the people who do so much
to help others build worthwhile lives and safe communities. Such experiences beg the question that if we
cannot believe people are able to change, then what is the point in treatment?
It can feel that we are simply moving the deckchairs around and biding time as
the Titanic sinks. Treatment – especially belief in treatment – is fundamental
to its process. If we want clients like this young man to cooperate and
prosper, then we need to have buy-in throughout the whole multidisciplinary system,
not just a few members of staff. Risk management is not simply about
containment and control, it’s about skill-building, desistance, and change. When
we are caught up in our client’s journeys, then their successes and failures
reflect on us. The staff was not acutely burned out yet, but neither were they
allowed to work at their best. Instead, they found themselves in an ongoing
state of lamenting that so many of their efforts were unrecognized, undervalued,
and disrespected.

In 2018, Simon Talbot and Wendy Dean
wrote an article
on what they termed the “moral injury” of physicians who do not have the
opportunity to be as effective as they could be. More recently, they have noted
that these professional moral injuries are the precursors to burnout. They
state:

“We
have come to believe that burnout is the end stage of moral injury, when
clinicians are physically and emotionally exhausted with battling a
broken system in their efforts to provide good care; when they feel
ineffective because too often they have met with immovable barriers to
good care; and when they depersonalize patients because emotional
investment is intolerable when patient suffering is inevitable as a result of
system dysfunction.

“We
believe that moral injury occurs when the basic elements of the medical
profession are eroded. These are autonomy, mastery, respect, and
fulfillment, which are all focused around the central principle
of purpose.”

As the authors note, autonomy is a
basic element of training. Whether we are physicians or mental health
clinicians, we are taught to think independently when considering diagnoses and
to guard against the competing interests of those who may try to sway our
treatment decisions away from our patients’ best interests. However, in many
facets of our work, we are required to forfeit our autonomy and allow other
interests to sway our decisions about care—most commonly for financial reasons.
This can be a serious consideration for professionals who feel pressured into
ethically questionable actions and whose licenses may be on the line.

When our own autonomy, mastery, fulfillment,
and sense of respect are constantly on the line, how can we expect to be at our
most effective with clients? Ultimately, this poses its own dilemmas related to
public safety.

Friday, January 17, 2020

New official statistics from the Crime Survey for England and Wales (CSEW) state
that one in five adults in the UK aged 18 – 74 have experienced at least one
form of child abuse before the age of 16. The survey estimates this at
approximately 8.5 million people. While this figure may seem shocking at first,
it actually reinforces what we know about child abuse prevalence and hints that
this maybe the tip of the iceberg, with these numbers being an underestimation
and not an overestimation. The report indicates that (please note that the
below statistics are directly quoted from the report);

In
the year ending March 2019, Childline
(a free service where children and young people in the UK can talk to a
counsellor about anything) delivered 19,847 counselling sessions to
children in the UK where abuse was the primary concern; around 1 in 20 of
the sessions resulted in a referral to external agencies;

As
of 31 March 2019, 49,570 children in England and 4,810 children in Wales
were looked after by their local authority because of experience or risk
of abuse or neglect;

Around
4 in 10 adults (44%) who were abused before the age of 16 years
experienced more than one of emotional abuse, physical abuse, sexual
abuse, or witnessing domestic violence or abuse. This proportion is higher
for women than men (46% compared with 41%);

Sexual
abuse was reported in around two-thirds (63%) of calls to National
Association for People Abused in Childhood’s helpline;

Around
half of adults (52%) who experienced abuse before the age of 16 years also
experienced domestic abuse later in life; compared with 13% of those who
did not experience abuse before the age of 16 years.

Previously in this blog we have talked about the challenges of
understanding the base rate data on experiences of sexual abuse, which is just
as important for broader definitions of abuse. We know that there is under
reporting, under recording, poor prosecution rates, cases being dropped, and
acquittals within the system. The volume of people sentenced for abuse does not
accurately reflect the volume of abuse that there is. This new data from
England and Wales, as Scotland and Northern Ireland collect and record data separately,
data is more than likely an underestimation, especially given the way that the
CSEW is constructed. That is, it relies on (1) self-completion modules of
Survey by men and women aged 16 and over who are resident in households in
England and Wales, & (2) offences reported to and recorded by the police.
Therefore, if you have not reported a crime to the police or are not a home
owner you are unable to take part. Interestingly, in recent years the CSEW have
contacted some children between 10 -15 to take part to get a broader spectrum.

The data from the CSEW highlights the challenges that child abuse
causes in England and Wales, especially in terms of trauma, Adverse Childhood
Experiences, ongoing development impacts and the costs/demands on the social
care and criminal justice systems. The growing recognition of ACE’s and past
trauma in our adult victims and perpetrators population is massive in the UK,
with Scotland and Wales putting it at the heart of their social
care and social welfare policies; however, it has not been as straightforward
for England and Northern Ireland. The CSEW data really highlights the need for
a more preventative/interventionist approach to child abuse. We need to
intervene sooner and develop more coherent secondary prevention approaches to
reduce child abuse. We also need to provide those at risk of abusing others with
the skills to prevent offending and to assist those at risk of being victimized
to be better safeguarded.

Friday, January 10, 2020

Not many
professionals are aware that the world’s largest adult pornography site,
Pornhub, publishes annual statistics
about its use and users. Obviously, readers will want to be judicious in how
they read the report (in the language of porn, the website itself is NSFW or
“not suitable for work”), although the findings themselves are presented in a
provocative but not necessarily offensive manner. Each reader’s opinions will
vary.

What have we
learned about Pornhub this year? Once again, the numbers are vast: In 2019
alone, there were 42 billion visits to the site (averaging 115 million per
day), 39 billion searches performed, and 6.83 million uploads. For just the
videos uploaded in 2019, if one were to watch them all in sequence, beginning
in 1850, they would still be watching today. Reading such statistics as “6597
petabytes of data transferred” is a little bit like trying to come to terms
with the national debts of nations; it can be nearly impossible to comprehend.

Beyond this, the
statistics track, to the best of their abilities, who the most popular stars
are, what people search for, what they actually watch, for how long, and where.
They also report on the age and gender of their viewers, leading to questions
of how they are able to divine this information (and is there a bias in the
direction of attracting advertisers). Nonetheless, the data is remarkable.

Digging a little
deeper, however, it seems that there is much we can learn about sex and
sexuality that can inform our understanding of clients in assessment and
treatment situations. First, of course, is obvious: Porn is ubiquitous.
Even the best available research does not show it to be a risk factor for
re-offense, as this earlier
blog describes. Pornography continues to be controversial,
with some politicians declaring it a public health crisis despite the
most recent scientific findings. To our minds, the most interesting and
concerning questions have to do with the effects of pornography on children, adolescents,
and other vulnerable people. The reality is that porn without context, as ill-informed
sexual education, lays problematic, difficult and unrealistic notions of sex
and sexuality; as indicated in a recent BBC
poll suggesting that women’s exposure to violent sex and violence during
sex is on the increase. Hence, we need sex education, informed debate and
realistic relationship expectations in modern society.

Questions arise:
These findings show that what people search for is not necessarily what they
end up watching. Further, as the authors of the report note, there is a trend
in the direction of real people and not simply actors. “Amateur” was amongst
the most frequent search terms, leading to questions about to what extent
viewers are looking for the most authentic or genuine experience (as opposed to
the gymnastics of many of the more commercially produced videos). At the same
time, however, animated pornography is also at the top of the list, speaking to
the role of novelty and fantasy for many viewers. These trends raise questions
for how we understand our clients in treatment as well as those on other
problematic pathways. As the Internet
Watch Foundation points out child sexual abuse material, and related
content, is often viewed on Facebook, Twitter, and other legally accessible
internet sites, not purely on the dark web. Most of this accessible material is
homemade, not “produced” which is in line with trends in mainstream porn.

Many more
questions follow regarding what people watch. There is plenty to be offended by
and concerned by. The prevalence of incest themes (mothers, fathers, stepmothers,
stepsisters, “Daddy” etc.) can and should raise any number of questions for
those understanding the sexuality of clients in treatment. On one hand, many
professionals working with adolescents who have sexually abused report seeing
cases in which these themes were used in the service of abusing within
families. On the other hand, one wonders about the underlying allure of the
relational aspects. As repulsive as incest is to society, do these videos also,
however strange it may seem, provide a sense of connection to viewers? What is
clear is that, as we have argued in the past, viewing porn through the lens of
our own
individual sense of morality is not a tenable approach to understanding or
treating people who have abused.

In the end, the
statistics provide more questions than answers. What do we really know about
the sexual interests of viewers? 32% of visitors were female, indicating that
it’s not as simple as men wanting to look at naked women. What will be the
long-term effects on young people who grow up porn-educated and without funding
for meaningful sex education in schools? And ultimately, what are people really
looking for when they enter the search terms that they do?

Kieran McCartan, PhD

Chief Blogger

David Prescott, LICSW

Associate blogger

Translate

The Association for the Treatment of Sexual Abusers (http://atsa.com/) is an international, multi-disciplinary organization dedicated to preventing sexual abuse. Through research, education, and shared learning ATSA promotes evidence based practice, public policy and community strategies that lead to the effective assessment, treatment and management of individuals who have sexually abused or are risk to abuse.

The views expressed on this blog are of the bloggers and are not necessarily those of the Association for the Treatment of Sexual Abusers, Sexual Abuse: A Journal of Research & Treatment, or Sage Journals.

Disclaimer

ATSA does not endorse, support, represent or guarantee the completeness, truthfulness, accuracy, or reliability of any Content posted. ATSA does not necessarily or automatically endorse any opinions expressed within this blog. You understand that by reading this blog, you may be exposed to content or opinions that might be offensive, harmful, inaccurate or otherwise inappropriate. Under no circumstances will ATSA be liable in any way for any Content, including, but not limited to, any errors or omissions in any Content, or any loss or damage of any kind incurred as a result of the use of any Content or opinions posted, emailed, transmitted, or otherwise made available via this blog.